Endocrine NCLEX Questions (71-75)

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71. A client undergoes a thyroidectomy and the nurse monitors the client for signs of damage to the parathyroid glands postoperatively. Which of the following findings would indicate damage to the parathyroid glands?

a) neck pain
b) hoarseness
c) respiratory distress
d) tingling around the mouth

72. A nurse is conducting a health history on a client with hyperparathyroidism. Which of the following questions asked of the client would elicit information about this condition?

a) do you have tremors in your hands?
b) are you experiencing pain in your joints?
c) have you had problems with diarrhea lately?
d) do you notice any swelling in your legs at night?

73. A client is admitted to the hospital in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares to administer which of the following medications as a primary initial treatment for this problem?

a) potassium
b) regular insulin
c) calcium gluconate
d) sodium bicarbonate

74. A client with Cushing's syndrome is being instructed by the nurse on follow-up care. Which statement by the client would indicate a need for further instructions?

a) I should avoid contact sports
b) I should check my ankles for swelling
c) I need to avoid foods high in potassium
d) I need to check my blood glucose regularly

75. A client with hyperaldosteronism is being treated with spironolactone (Aldactone)> Which of the following indicates to the nurse that the medication is effective?

a) a decrease in blood pressure
b) a decrease in sodium excretion
c) a decrease in body metabolism
d) a decrease in plasma potassium





Endocrine NCLEX Questions
Answers and Rationale

71) D

- The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek's and Trousseau's signs. Hoarseness and neck pain are expected findings postoperatively. Respiratory distress indicates a complication but is not a sign of damage to the parathyroid glands.

72) B

- Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain, and pathological fractures. Options A and C relate to assessment of hypoparathyroidism. Option D is unrelated to hyperparathyroidism.

73) B

- The primary treatment for any acid-base imbalance is the treatment of the underlying disorder that caused the problem. In this case, the underlying cause of the metabolic acidosis is anaerobic metabolism caused by the lack of the ability by the body to use circulating glucose. The administration of insulin corrects this problem. Potassium may be added to the treatment regimen if serum potassium levels indicate it is necessary. Options C and D would not be used in the treatment of this disorder.

74) C

- Hypokalemia is a common characteristic of Cushing's syndrome, and the client is instructed to consume foods high in potassium. Clients also experience activity intolerance, osteoporosis, and frequent bruising. Excess fluid volume results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion.

75) A

- Aldactone antagonizes the effect of aldosterone and decreases circulating volume by inhibiting tubular reabsorption of sodium and water. Thus, it produces a decrease in blood pressure. It increases the excretion of sodium and water and increases potassium retention. It has no effect on body metabolism.


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Endocrine System Questions and Answers (66-70)

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66. The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addison's crisis?

a) prednisone (deltasone)orally
b) fludrocortisone (Florinef) subcutaneously
c) spironolactone (Aldactone) intramuscularly
d) methiprednisolone sodium succinate (Solu-Medrol) intravenously

67. The nurse is preparing a client with Graves' disease to receive radioactive iodine therapy. The nurse tells the client which of the following about the therapy?

a) following the initial dose, subsequent treatments must continue lifelong
b) the radioactive iodine is designed to destroy the entire thyroid gland with just one dose
c) it takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease
d) the high levels of radioactivity prohibit contact with family for 4 weeks after initial treatment

68. The nurse is preparing to care for a client returning from the operating room following a subtotal thyroidectomy. The nurse anticipates the need for which of the following items to be placed at the bedside?

a) hypothermia blanket
b) emergency tracheostomy kit
c) magnesium sulfate in a ready-to-inject vial
d) ampule of saturated solution of potassium iodide (SSKI)

69. The nurse is admitting a client with a diagnosis of myxedema to the hospital. The nurse performs which of the following that will provide data related to this diagnosis?

a) inspects facial features
b) auscultates lung sounds
c) percusses the thyroid gland
d) palpates the adrenal glands

70. A nurse is preparing postoperative discharge instructions for a client who had one adrenal gland removed. The nurse includes which of the following in the instructions?

a) the reason for maintaining a diabetic diet
b) teaching proper application of an ostomy pouch
c) instructions about early signs of a wound infection
d) the need for lifelong replacement of all adrenal hormones







Endocrine System Questions and Answers and Rationale

66) D

- A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy. Aldactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid.

67) C

- Following treatment with radioactive iodine therapy, a decrease in thyroid hormone level should be noted, which would help alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse needs to reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates. Occasionally, a client may require a second or third dose, but treatments are not lifelong.

68) B

- Respiratory distress can occur following thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem post-thyroidectomy. SSKI is typically administered preoperatively to block thyroid hormone synthesis and release, as well as to place the client in a euthyroid state.

69) A

- Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristic of myxedema. The assessment techniques in options B, C, and D will not reveal information related to the diagnosis of myxedema.

70) C

- A client who had a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Also, because of the anti-inflammatory properties of corticosteroids produced by the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present. The client does not need to maintain a diabetic diet, and the client will not have an ostomy following this surgery.



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Endocrine System Questions and Answers (61-65)

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61. A client with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse places highest priority on which of the following nursing diagnoses developed for this client?

a) risk for infection
b) disturbed body image
c) ineffective health maintenance
d) risk for deficient fluid volume

62. A nurse is caring for a client with a diagnosis of Cushing's syndrome. The nurse plans which of these measures to prevent complications from this medical condition?

a) monitoring glucose level
b) encouraging daily jogging
c) monitoring epinephrine levels
d) encouraging visits form friends

63. A nurse notes on the cardiac monitor that a client with aldosteronism is experiencing a dysrhythmia. The nurse immediately assesses the client's:

a) peripheral pulses
b) intake and output
c) superficial reflexes
d) plasma potassium level

64. A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which of the following that is most likely to occur in this client?

a) hypovolemia
b) hypoglycemia
c) mood disturbances
d) deficient fluid volume

65. The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor that is producing excessive aldosterone (primary hyperaldosteronism). The nurse appropriately tells the client which of the following?

a) you will need to wear an abdominal binder after surgery
b) you will most likely need to undergo chemotherapy after surgery
c) you will need to take hormone replacements for the rest of your life
d) you will not require any special long-term treatment after surgery






Endocrine System Questions and Answers and Rationale

61) A

- The client with a stab wound has a break in the body's first line of defense against infection. The client with Cushing's disease is at great risk for infection caused by excess cortisol secretion, subsequent impaired antibody function, and decreased proliferation of lymphocytes. The client may also have an Ineffective health maintenance and Disturbed body image, but these are not the highest priority at this time. The client would be at risk for Excess fluid volume, not Deficient fluid volume, with Cushing's disease.

62) A

- In the client with Cushing's syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus. Epinephrine levels are not affected. Clients experience activity intolerance related to muscle weakness and fatigue, therefore option B is incorrect. Visitors should be limited because of the client's impaired immune response.

63) D

- Aldosteronism can lead to hypokalemia, which in turn can cause life-threatening dysrhythmias. Options A, B, and C are not immediate priorities for this client.

64) C

- When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention, producing edema and hypertension.

65) C

- The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy will need permanent replacement of adrenal hormones. Options A, B, and D are inaccurate.



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Endocrine System Questions and Answers (56-60)

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56. A nurse is preparing to care for a client following parathyroidectomy. The nurse plans care anticipating which postoperative order?

a) maintain the endotracheal tube for 36 hours
b) take a rectal temperature only until discharge
c) ensure that intravenous calcium preparations are available
d) place the client in a flat position with the head and neck immobilized

57. While a client with myxedema is being admitted to the hospital, the client reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse knows that these symptoms are caused by a lack of production of which hormone(s)

a) luteinizing hormone (LH)
b) adrenocorticotropic hormone (ACTH)
c) triiodothyronine (T3) and thyroxine (T4)
d) prolactin (PRL) and growth hormone (GH)

58. A 33-years old female is admitted to the hospital with a suspected diagnosis of grave's disease. Which symptom related to the client's menstrual cycle would the client likely report?

a) amenorrhea
b) metrorrhagia
c) menorrhagia
d) dysmenorrha

59. A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is most at risk of developing which type of acid-base imbalance?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

60. The home care nurse is developing a plan of care for an older client with diabetes mellitus who has gastroenteritis. In order to maintain food and fluid intake to prevent dehydration, the nurse plans to:

a) offer water only until the client is able to tolerate solid foods
b) withhold all fluids until vomiting has ceased for at least 4 hours
c) encourage the client to take 8 to 12 ounces of fluid every hour while awake
d) maintain a clear liquid diet for at least 5 days before advancing to solids to allow inflammation of the bowel to dissipate






Endocrine System Questions and Answers Rationale

56) C

- Hypocalcemia is a potentially life-threatening complication following parathyroidectomy, and the nurse should ensure that intravenous calcium preparations are readily available. Semi-Fowler's position is the position of choice to assist in lung expansion and prevent edema. Rectal temperatures are not required. Tympanic temperatures can be taken. The client will not necessarily have an endotracheal tube.

57) C

- Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.

58) A

- Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Dysmenorrhea, metrorrhagia, and menorrhagia are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease.

59) A

- Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options B, C, and D are incorrect.

60) C

- The client should be offered liquids containing both glucose and electrolytes. Small amounts of fluid may be tolerated, even when vomiting is present. The diet should be advanced as tolerated and include a minimum of 100 to 150 grams of carbohydrates daily. Offering water only and maintaining liquids for 5 days will not prevent dehydration but may promote it in this client.


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Heart Failure NCLEX Questions 71-75

Welcome to Heart Failure NCLEX Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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71. The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. The nurse should use which of the following methods to cover the dressing?

a) apply a kerlix roll and tape it to the skin
b) apply a large, soft pad, and tape it to the skin
c) apply small Montgomery straps and tie the edges together
d) apply a Kling roll and tape the edge of the roll onto the bandage

72. A client develops bilateral wheezes, crackles from bases to apices, orthopnea, and tachypnea, and the nurse notes the presence of +2 pitting edema. The nurse suspects pulmonary edema and notifies the physician. While awaiting the physician's arrival, the nurse avoids which action?

a) elevating the client's legs
b) preparing to administer IV morphine sulfate
c) preparing to administer IV furosemide (Lasix)
d) placing the client in the high Fowler's position

73. Heart Failure NCLEX Questions about the nurse who is caring for a client scheduled to undergo a cardiac catheterization for the first time. The nurse tells the client that the:

a) procedure is performed in the operating room
b) initial catheter insertion is quite painful; after that, there is little or no pain
c) client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard x-ray table for about 4 hours
d) client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations


74. A nurse admits a client with myocardial infarction (MI) to the coronary care unit (CCU). The nurse plans to do which of the following in delivering care to this client?

a) begin thrombolytic therapy
b) place the client on continuous cardiac monitoring
c) infuse intravenous (IV) fluid at a rate of 150 ml per hour
d) administer oxygen at a rate of 6 liters per minute by nasal cannula

75. The nurse is analyzing an ECG rhythm strip on an assigned client. The nurse notes that there are three small boxes from the beginning of the "P" wave to the "R" wave. The nurse records that the client's PR interval is:

a) 0.12 second
b) 0.20 second
c) 0.24 second
d) 0.40 second





Heart Failure NCLEX Questions
Answers and Rationale

71) D

- With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps could not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway). Standard dressing technique includes the use of Kling rolls on circumferential dressings.

72) A

- Elevating the client's legs would rapidly increase venous return to the right side of the heart and worsen the client's condition. The feet should be in the horizontal position, or the client could dangle at the bedside if the client's condition permits. Anxiety causes an increase in the oxygen demands on the heart. Morphine sulfate reduces anxiety and causes peripheral vasodilation and is likely to be prescribed. Furosemide will be prescribed because of its diuretic action. A high Fowler's position increases the thoracic capacity, allowing for improved ventilation.

73) D

- Heart Failure NCLEX Questions Rationale: Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so there is little to no pain with catheter insertion. The X-ray table is hard and may be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.

74) B

- Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring, administering oxygen at a rate of 2 to 4 liters per minute unless otherwise ordered, and ensuring an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep vein open rate to prevent fluid overload and heart failure. Thrombolytic therapy may or may not be prescribed by the physician. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event.

75) A

- Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.


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Heart Failure NCLEX Questions 1-5

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Cardiac Nurse Education (66-70)

Welcome to Cardiac Nurse Education. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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66. The nurse is preparing to initiate an intravenous nitroglycerin drip on a client with acute myocardial infarction. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside?

a) defibrillator
b) pulse oximeter
c) central venous pressure (CVP) tray
d) noninvasive blood pressure monitor

67. A client is in ventricular tachycardia and the physician orders intravenous (IV) lidocaine (xylocaine). The nurse plans to dilute the concentrated solution of lidocaine with:

a) lactated ringer's
b) normal saline 0.9%
c) 5% dextrose in water
d) normal saline 0.45%

68. A client who recently experienced a myocardial infarction is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). The nurse plans to teach the client that, during this procedure, a balloon-tipped catheter will:

a) inflate a meshlike device that will spring open
b) be used to compress the plaque against the coronary blood vessel wall
c) cut away the plaque from the coronary vessel wall using a cutting blade
d) be positioned in coronary artery to take pressure measurements in the vessel

69. A nurse is planning care for the client with heart failure. The nurse asks the dietary department to remove which item from all meal trays before delivering them to the client?

a) 1% milk
b) margarine
c) salt packets
d) decaffeinated tea


70. A client has just been admitted to the emergency department with chest pain. Serum enzyme levels are drawn, and the results indicate an elevated serum creatinine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with:

a) stable angina
b) unstable angina
c) prinzmetal's angina
d) new-onset myocardial infarction (MI)







Cardiac Nurse Education
Answers and Rationale

66) D

- Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.

67) C

- Lidocaine for IV administration is dispensed in concentrated and dilute formulations. The concentrated formulation must be diluted with 5% dextrose in water.

68) B

- In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option C describes coronary atherectomy, option A describes placement of a coronary stent, and option D describes part of the process used in cardiac catheterization.

69) C

- Sodium restriction reduces water retention and improves cardiac efficiency. A standard dietary modification for the client with heart failure is sodium restriction.

70) D

- Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise 3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Therefore, the client's results are compatible with new-onset MI. Options A, B, and C all refer to angina. These levels would not be elevated in angina.



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Cardiac Nurse Education (61-65)

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61. The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. The appropriate nursing action is to:

a) prepare for defibrillation
b) continue to monitor the rhythm
c) notify the physician immediately
d) prepare to administer lidocaine hydrochloride (xylocaine)

62. The nurse is caring for a client who has been transferred to the surgical unit after having a pelvic exenteration. During the postoperative period, the client complains of pain in the calf area. What action should the nurse take?

a) ask the client to walk and observe the gait
b) lightly massage the calf area to relieve the pain
c) check the calf area for temperature, color, and size
d) administer prn morphine as prescribed for postoperative pain

63. A client has developed atrial fibrillation and has a ventricular rate of 150 bpm. The nurse assesses the client for:

a) flat neck veins
b) nausea and vomiting
c) hypotension and dizziness
d) hypertension and headache

64. A 45 year old client is admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia noted on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client?

a) you will continue to take your medications until the morning of the test
b) you will be sedated during the procedure and will not remember what has happened
c) this test is a noninvasive method of determining the effectiveness of your medication
d) during the procedure, a special wire is used to increase the heart rate and produce the irregular beats that caused your signs and symptoms

65. A nurse is providing diet teaching to a client with congestive heart failure (CHF). The nurse tells the client to avoid which of the following?

a) sherbet
b) steak sauce
c) apple juice
d) leafy green vegetables






Cardiac Nurse Education
Answers and Rationale

61) B

- As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the physician needs to be notified.

62) C

- The nurse monitors for postoperative complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options A and B could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client complaint is not the appropriate nursing action. Further assessment needs to take place.

63) C

- The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

64) D

- The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmias without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.

65) B

- Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with CHF should monitor sodium intake.


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